Expansion of healthcare coverage associated with increased primary care utilization and quality

1. Affordable Care Act-related expansion of Medicaid coverage or private insurance coverage for low-income adults was associated with improved preventative healthcare, outpatient utilization, quality markers and satisfaction of care.

2. There were no significant differences between strategies of care expansion through either Medicaid expansion or using federal funds to purchase private insurance for low-income adults. However, there was a difference between this strategy compared with no expansion at all.

Evidence Rating Level: 3 (Average)   

Study Rundown: Expansion of healthcare coverage under the Affordable Care Act (ACA) has allowed many low-income adults to obtain healthcare coverage. However, there has not yet been demonstrated improved utilization, preventative care, or health outcomes. This current study sought to examine differences in health care associated outcomes in the population of low-income adults for three states (Kentucky, Arkansas, and Texas) who have undertaken different approaches to the ACA. While Texas has not undergone expansion of coverage, Kentucky has expanded Medicaid coverage, and Arkansas has used funds to purchase private insurance.

Two-years following implementation of Medicaid/private insurance expansion, uninsured rates dropped significantly more in Arkansas and Kentucky compared to Texas. Coverage expansion was associated with improved access to care with more patients obtaining a family physician, decreased reliance on the Emergency Department, and reduction in cost-related barriers to care. There was also increased screening for and management of diabetes, and more regular care for chronic conditions. Satisfaction with care was also increased. There were no major differences between the Medicaid, or private expansion strategies. The strength of the study included the evaluation of all three strategies after the ACA, and the study allowed for enough time to evaluate health outcomes, which take several years after implementation of a large-scale policy. However, major health outcomes have yet to be investigated. Generalizability to other states with different rates of uninsured adults may be limited. The reliance on survey data may introduce confounders and response bias that have not been accounted for in the present analysis.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: The Affordable Care Act at 5 Years

In-Depth [case-control study]: This study surveyed 8676 adults (aged 19 to 64 years) from Texas, Arkansas, and Kentucky in the years 2013 to 2015 who had family incomes below 138% of the federal poverty level. The survey was conducted by random-digit telephone survey of landlines and cell phones. Texas had greater numbers of Latinos and participants from urban settings. Expansion states (Arkansas and Kentucky) had significantly greater reduction in uninsured rates (22.7 percentage points, p < 0.001) compared with non-expansion (Texas).

Compared to the non-expansion state, the respondents in expansion states had significant improvements in primary outcomes of: personal physician (p < 0.001), usual location of care as ED (p = 0.4), cost-related delays in obtaining care (p < 0.001), or medications (p < 0.001), difficulty paying medical bills (p < 0.001), out-of-pocket spending (29.5% reduction, p = 0.02), glucose monitoring (p = 0.05), care for chronic conditions (p = 0.008), and self-reported quality of care (p = 0.04). There were no significant differences in primary outcomes between the two strategies of care expansion aside from increased glucose monitoring rates for diabetics in Kentucky (11.6 percentage point difference, p = 0.04).

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